Jill Scott-Cawiezell

Barriers to safe medication administration in the nursing home--Exploring staff perceptions and concerns about the medication use process

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:51:03 PST

The purpose of this study was to explore staff perceptions and concerns about the medication use process in the nursing home setting. A total of 76 staff members from 5 nursing homes in 3 Midwestern states participated in key informant interviews and focus groups. Common themes included issues related to communication, competing demands, and the challenges of a paper-based medication administration record. Concerns frequently were associated with the timeliness and accuracy of the medication administration process. Recognition of staff concerns are an important first step in improving the nursing home medication use process. Staff insight provided clarification related to impediments to safe medication practices. This study provides insight into how technology can improve the nursing home medication use process.

Guiding inpatient quality improvement: A systematic review of lean and six sigma

J. M. Glasgow et al. — Mon, 07 Nov 2011 13:50:57 PST

Background: Two popular quality improvement (QI) approaches in health care are Lean and Six Sigma. Hospitals continue to adopt these QI approaches -- or the hybrid Lean Sigma approach -- with little knowledge on how well they produce sustainable improvements. A systematic literature review was conducted to determine whether Lean, Six Sigma, or Lean Sigma have been effectively used to create and sustain improvements in the acute care setting. Methods: Databases were searched for articles published in the health care, business, and engineering literatures. Study inclusion criteria required identification of a Six Sigma, Lean, or Lean Sigma project; QI efforts focused on hospitalized patients; descriptions of project improvements; and reported results. Depending on the quality of data reported, articles were classified as summary reports, pre-post observational studies, or time-series reports. Results: Database searches identified 539 potential articles. After review of titles, abstracts, and full text, 47 articles met inclusion criteria -- 10 articles summarized multiple projects, 12 reported Lean projects, 20 reported Six Sigma projects, and 5 reported Lean Sigma projects. Generally, the studies provided limited data, with only 15 articles providing any sort of follow-up data; of the 15, only 3 report a follow-up period greater than two years. Conclusion: Lean, Six Sigma, and Lean Sigma as QI approaches can aid institutions in tackling a wide variety of problems encountered in acute care. However, the true impact of these approaches is difficult to judge, given that the lack of rigorous evaluation or clearly sustained improvements provides little evidence supporting broad adoption. There is still a need for future work that will improve the evidence base for understanding more about QI approaches and how to achieve sustainable improvement.

Measuring pain intensity in nursing home residents

K. R. Jones et al. — Mon, 07 Nov 2011 13:50:52 PST

Assessing pain intensity in nursing home residents remains a challenge. As part of a multifaceted intervention study to improve pain practices in nursing homes, quarterly pain assessments were conducted in 12 Colorado nursing homes. Residents who reported pain or discomfort of any kind in the past 24 hours were asked to choose one of three pain intensity scales to quantify their current and highest level of pain intensity. They were also observed for pain behaviors using Feldt's Checklist of Nonverbal Pain Indicators. Residents preferred the Verbal Descriptor Scale almost 2:1 over the 11-point Verbal Numeric Rating Scale and the Faces Pain Scale. Sex and ethnicity were associated with differences in scale preference. More than one-half of residents reporting pain had an observable pain indicator. There was a monotonic relationship between reported pain intensity and number of observed pain indicators. To improve pain assessment and management in nursing homes, residents should be given a choice of pain intensity scales and observed for possible pain behaviors.

Nursing home culture: A critical component in sustained improvement

Jill Scott-Cawiezell et al. — Mon, 07 Nov 2011 13:50:47 PST

In the third in a series of articles exploring working conditions and quality improvement in nursing homes, 31 nursing homes were surveyed using an adaptation of the Competing Values Framework (CVF) Organizational Assessment. The CVF provides information about the organizational culture through describing dominant perceived values, distribution of values across organizational characteristics, and orientation of values toward flexibility. Staff reported a dominant group culture, reflecting a family and team orientation within their settings. Leaders, however, were more often reported to reflect a hierarchy value orientation, emphasizing efficiency of operations and following rules and procedures.

Technology implementation and workarounds in the nursing home

A. A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:50:41 PST

OBJECTIVE: This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes. DESIGN: As a part of a larger study, this qualitative evaluation was conducted to identify workarounds associated with the implementation of an electronic medication administration record. Data were collected using multimethods including direct observation, process mapping, key informant interviews, and review of field notes from medication safety team meetings. MEASUREMENTS: Open and axial coding techniques were used to identify and categorize types of workarounds in relation to work flow blocks. RESULTS: Workarounds presented in two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team. CONCLUSION: This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety.

Exploring nursing home staff's perceptions of communication and leadership to facilitate quality improvement

Jill Scott-Cawiezell et al. — Mon, 07 Nov 2011 13:50:36 PST

Leadership and clinical staff were surveyed to explore communication and leadership in nursing homes. Registered nurses and other professionals perceived communication as better than their nursing colleagues did. Overall, results suggest all factors of communication could improve. In terms of leadership, licensed practical nurses perceived less clarity of expectations, encouragement of initiative, and support than other groups. The study provides insight into what is organizationally necessary to improve quality of care in nursing homes.

Developing a statewide medication technician pilot program in nursing homes

P. K. Randolph et al. — Mon, 07 Nov 2011 13:50:32 PST

In times of fiscal constraints, nursing homes are seeking to maximize use of licensed staff through delegation of low-risk tasks to unlicensed personnel. Between 2004 and 2008, the Arizona State Board of Nursing developed and conducted a pilot program to determine the impact on patient health and safety of licensed nurses delegating medication administration to trained certified nursing assistants. There were no differences in patterns of medication errors before and after the introduction of medication technicians, and structured interviews revealed that participants viewed the role favorably, with reported increased role satisfaction on the part of delegating nurses. Efforts are underway to extend the program statewide.

Achieving quality improvement in the nursing home: Influence of nursing leadership on communication and teamwork

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:50:28 PST

Leadership, communication, and teamwork are essential elements of organizational capacity and are linked to organizational performance. How those organizations actually achieve improved performance, however, is not clearly understood. In this comparative case study, nursing leadership who facilitated open communication and teamwork achieved improvement while nursing leadership who impeded open communication and teamwork did not.

Detection of patient risk by nurses: A theoretical framework

L. A. Despins et al. — Mon, 07 Nov 2011 13:50:23 PST

AIM: This paper is a description of a theoretical framework of how nurses detect and interpret patient risk signals in the context of organizational attitudes and procedures related to patient safety. BACKGROUND: The ability to detect when patients are at increased risk for harm is a challenge faced by nurses worldwide. How nurses are able to discriminate patient risk warning signals from background noise is not well understood. Also, the impact of system-level factors on nurses' signal detection capabilities has not been investigated. DATA SOURCES: Computerized database searches were used to identify nursing, organizational science, and cognitive psychology literature from 1964 to 2009 pertinent to the framework. DISCUSSION: The patient risk detection theory synthesizes concepts of signal detection theory and high reliability theory. Signal detection theory explains the decision-making processes of nurses as they scan for signals of potential patient harm. High reliability theory explains how nurses' signal detection capacities are facilitated when healthcare settings operate as high reliability organizations making patient safety the top priority. CONCLUSION: The patient risk detection theory facilitates understanding of both individual and organizational factors that influence nurses' ability to detect risk in complex healthcare settings. It can be used to guide research on interventions to enhance signal detection by nurses and increase patient safety in today's complex care environments. The theory can also be used to guide design of training programmes that permit nurses to develop practical skills in signal detection.

An exploration of nursing home organizational processes

S. Forbes-Thompson et al. — Mon, 07 Nov 2011 13:50:19 PST

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.

Quality improvement in long-term care. Are nursing homes ready to create sustainable improvement?

Jill Scott-Cawiezell — Mon, 07 Nov 2011 13:50:13 PST

Influencing leadership perceptions of patient safety through just culture training

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:50:08 PST

There are differences in perceptions of safety culture between healthcare leaders and staff. Evidence suggests that an organization's actual safety performance is more closely reflected in staff perceptions suggesting that frontline staff may be more aware than the leadership of actual patient safety challenges within their organization. Closing the perception gap between healthcare leaders and staff is critical to aligning the resources and strategies required to create a true culture of safety.

Medication error reporting in LTC

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:50:02 PST

In settings where patients are susceptible to adverse drug reactions, management of medication errors is acutely important. Efforts to reduce and prevent such events are, however, complicated by punitive medication management systems that make staff reluctant to report errors. By removing punitive medication error reporting systems, facility leaders can foster safer medication systems.

A just culture: The role of nursing leadership

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:49:56 PST

Organizational climate of staff working conditions and safety-An integrative model

P. W. Stone et al. — Mon, 07 Nov 2011 13:49:51 PST

Objectives: This project sought to compare measures of organizational climate in ongoing patient safety studies, identify similarities and setting-specific dimensions, develop a model of climate domains that are hypothesized to affect outcomes across settings, and test aspects of the model. Methods: Investigators who had surveyed health care workers' perceptions of organizational climate in six studies funded by the Agency for Healthcare Research and Quality (AHRQ) were invited to participate. Survey items from each study were classified using four climate domains found in a prior literature review. The authors discussed subconstructs, proposed additional constructs, developed an integrative model, and independently tested selected aspects of the model. Results: The investigators who participated had studied acute care, home health care, long-term care, and multiple settings; two investigators had studied primary care. More than 80,000 workers were surveyed. The model's core climate domains included leadership (e.g., values) and organizational structural characteristics (e.g., communication processes and information technology), the impact of which was mediated by four process variables: supervision, group behavior (e.g., collaboration), quality emphasis (e.g., patient centeredness), and work design (e.g., staffing). These factors affect health care worker outcomes (e.g., satisfaction and intention to leave) and patient outcomes. Overall, the full model explained 24 to 65 percent of the variance in employee satisfaction, but was not as effective at predicting intention to leave. Conclusions: While some of these domains appeared in prior models, new domains-quality emphasis, new subconstructs, information technology, and patient centeredness-are emerging. Our model invites dialogue among researchers and informs agenda-setting for future research into organizational climate and the safety of patients and health care employees. This integrative model will facilitate cross-study quantification of associations among variables in these important domains.

Nursing home error and level of staff credentials

Jill Scott-Cawiezell et al. — Mon, 07 Nov 2011 13:49:46 PST

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels of credentialing among nursing home staff who deliver medications (RN, LPN, or CMT/A) on medication error. In addition, the impact of distractions and interruptions was explored. Using naive observation, 39 medication administrators representing various levels of credentialing were unobtrusively observed to determine the number of medication errors, distractions, and interruptions in five nursing homes. There were no differences in medication error rates by level of credential. However, RNs had more interruptions during their medication administration, and these increased interruptions were associated with increased medication error rates when wrong time errors were excluded (p = .0348).

Entrepreneurial program of research and service to improve nursing home care

M. J. Rantz et al. — Mon, 07 Nov 2011 13:49:41 PST

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Are nursing homes ready to create sustainable improvement?

Jill Scott-Cawiezell — Mon, 07 Nov 2011 13:49:36 PST

Technology innovations. Barriers to safe medication administration in the nursing home: exploring staff perceptions and concerns about the medication use process

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:49:30 PST

The role of nursing leadership in successful technology implementation

A. Vogelsmeier et al. — Mon, 07 Nov 2011 13:49:26 PST